2021 MuGSI Extended-Spectrum Beta-Lactamase (ESBL)-Produ

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___ ___ - ___ ___ - ___ ___ ___ ___

1Extended-Spectrum Beta-Lactamase (ESBL)-Producing Enterobacteriaceae
0XOWLVLWH*UDP1HJDWLYH6XUYHLOODQFH,QLWLDWLYH0X*6,

Form Approved
OMB No. 0920-0978

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Patient’s Name:

Phone no. (

)
MRN:

Address:
City:

State

ZIP:

Hospital:

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□
□
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Hispanic or Latino
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Unknown

Native

Other Pacific Islander

□ White
□ Asian
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Extended-Spectrum Cephalosporin-resistant:

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ƑKlebsiella pneumoniae
ƑKlebsiella oxytoca

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□ Blood □ Bone □ CSF □ Internal body site (specify):___________ □ Joint/synovial fluid □ Muscle
□ Peritoneal fluid □ Pericardial fluid □ Pleural fluid □ Urine □ Other normally sterile site (specify): ______________

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Facility
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□ Clinic/Doctor's office
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□ OR
□ Radiology
□ Other inpatient

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□ Yes □ No □ Unknown
IF YES, DATE OF ADMISSION:

___ ___ - ___ ___ - ___ ___ ___ ___

□ Survived

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DATE OF DISCHARGE: ___ ___ - ___ ___ - ___ ___ ___ ___ OR

□ Date unknown

IF SURVIVED, DISCHARGED TO:

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□ Private residence
□ LTCF

Facility ID: _______________

□

Hospital inpatient
Facility ID: _______________
Was the patient transferred from
this hospital?

□ LTACH

Facility ID: ___________________

□ Homeless
□ Incarcerated
□ Other (specify):________________
□ Unknown

□ Yes □ No □ Unknown
D:$67+(3$7,(17,1$1,&8,17+('$<6%()25(7+(',6&"

□ Yes □ No □ Unknown

IF YES, DATE OF ICU ADMISSION: ___ ___ - ___ ___ - ___ ___ ___ ___ OR

□ Date unknown

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□ Yes □ No □ Unknown

IF YES, DATE OF ICU ADMISSION: ___ ___ - ___ ___ - ___ ___ ___ ___ OR

□ Died

DATE OF DEATH:

□ Private residence □ LTCF Facility ID:______ □ LTACH Facility ID: ______
□ Other (specify): ________ □ Unknown

___ ___ - ___ ___ - ___ ___ ___ ___ OR

□ Date unknown

□ Unknown
□ Date unknown

ON THE DAY OF OR IN THE 6 CALENDAR DAYS BEFORE DEATH, WAS THE PATHOGEN
OF INTEREST ISOLATED FROM A SITE THAT MEETS THE CASE DEFINITION?

□

Yes

□ No □ Unknown

Public reporting burden of this collection of information is estimated to average 28 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed,
and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number.
Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS
D-74, Atlanta, Georgia 30329; ATTN: PRA (0920-0978).

Version Date: 10/2020

PAGE 1 OF 4

Form Approved
OMB No. Form
0920-0978
Approved
OMB
No. 0920-0978
Exp. Date:
XX-XX-XXXX

□

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None
□ Epidural Abscess
□ Cellulitis
□
□ Abscess, not skin
□ Chronic ulcer/wound (not decubitus) □ Meningitis
□
□ AV fistula/graft infection
□ Osteomyelitis
□ Decubitus/pressure ulcer
□
□ Bacteremia
□ Peritonitis
□ Empyema
□
□ Bursitis
□ Pneumonia
□
□ Catheter site infection (CVC) □ Endocarditis

□ None □ Unknown

□ Unknown □ Colonized

Pyelonephritis
Septic arthritis
Septic emboli
Septic shock
Skin abscess

□
□
□
□
□

E5(&855(1787,

Surgical incision infection
Surgical site infection (internal)
Traumatic wound
Urinary tract infection
Other (specify): ____________

□ Yes
□ No
□ Unknown

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□
□

□ AIDS/CD4 count < 200

Chronic pulmonary disease

□ Primary immunodeficiency
□ Transplant, hematopoietic stem cell
□ Transplant, solid organ

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□ Diabetes mellitus
□ With chronic complications

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□ Chronic liver disease
□ Ascites
□ Cirrhosis
□ Hepatic encephalopathy
□ Variceal bleeding
□ Hepatitis C
□ Treated, in SVR
□ Current, chronic

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□
□
□
□
□

CVA/Stroke/TIA
Congenital heart disease
Congestive heart failure
Myocardial infarction
Peripheral vascular disease (PVD)

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□
□
□
□

□
□
□

19. SUBSTANCE86(

□
□
□
□
□
□
□
□

□
□
□

Malignancy, hematologic
Malignancy, solid organ (non-metastatic)
Malignancy, solid organ (metastatic)

ALCOHOL
ABUSE:

□ Unknown

□ Tobacco
□ E-nicotine delivery system
□ Marijuana

□ Yes
□ No
□ Unknown

□

□

□
□
□
□
□
□
□
□

DURING THE CURRENT HOSPITALIZATION, DID THE PATIENT RECEIVE
MEDICATION ASSISTED TREATMENT (MAT) FOR OPIOID USE DISORDER?

□ Yes □ No
□ Yes □ No □ Unknown

IF YES, DATE OF DISCHARGE CLOSEST TO DISC :___ ___ - ___ ___ - ___ ___ ___ ___
OR,

DATE UNKNOWN

□

Facility ID: __________

29(51,*+767$<,1/7&),17+(<($5%()25(',6&:
Facility ID: __________

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□ Yes □ No □ Unknown
□ Yes □ No □ Unknown

Facility ID: __________

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□ Yes □ No □ Unknown

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□ Yes □ No □ Unknown

IF YES, TYPE: □ Hemodialysis

□ Peritoneal □ Unknown

□ Unknown

_____kg

Version Date: 10/2020

1E+(,*+7

_________ft. _______ in. OR
_____cm 

□ Unknown

□ IDU
□ IDU
□ IDU
□ IDU
□ IDU
□ IDU
□ IDU
□ IDU

□ Skin popping
□ Skin popping
□ Skin popping
□ Skin popping
□ Skin popping
□ Skin popping
□ Skin popping
□ Skin popping

□ Non-IDU
□ Non-IDU
□ Non-IDU
□ Non-IDU
□ Non-IDU
□ Non-IDU
□ Non-IDU
□ Non-IDU

□ Unknown
□ Unknown
□ Unknown
□ Unknown
□ Unknown
□ Unknown
□ Unknown
□ Unknown

□ Yes □ No □ N/A (patient not hospitalized or did not have DUD)

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□ Yes □ No □ Unknown

Check here if central line in place for > 2 calendar days:Ƒ

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7+(7,0(2)&2//(&7,2125$7$1<7,0(,17+(

□ Yes □ No □ Unknown
IF YES, CHECK ALL THAT APPLY:
□ Indwelling Urethral Catheter □ Suprapubic Catheter

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□ Condom Catheter

□ Other (specify):__________

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727+(7,0(2)&2//(&7,2125$7$1<7,0(,17+(
&$/(1'$5'$<6%()25(',6& □ Yes □ No □ Unknown

IF YES, CHECK ALL THAT APPLY:

□ ET/NT Tube □ Gastrostomy Tube
□ Tracheostomy □ Nephrostomy Tube
PATIENT TRAVELED INTERNATIONALLY
IN THE YEAR BEFORE DISC:

□ AV fistula/graft □ Hemodialysis central line □ Unknown
_________lbs. ______ oz. OR

02'(2)'(/,9(5<&KHFNDOOWKDWDSSO\

□ NG Tube
□ Other (specify):
_____________

IF HEMODIALYSIS, TYPE OF VASCULAR ACCESS:

1D:(,*+7

DUD or abuse
DUD or abuse
DUD or abuse
DUD or abuse
DUD or abuse
DUD or abuse
DUD or abuse
DUD or abuse

□
□

Urinary tract problems/
abnormalities
Premature birth
Spina bifida

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&2//(&7,2125$7$1<7,0(,17+(&$/(1'$5

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Connective tissue disease
Obesity or morbid obesity
Pregnant

MuGSI CONDITIONS

Chronic kidney disease
Lowest serum creatinine: ________mg/DL
□ Unknown or not done

□ None □ Unknown

Burn
Decubitus/pressure ulcer
Surgical wound
Other chronic ulcer or chronic
wound
Other (specify):___________

□
□
□

RENAL DISEASE

Marijuana, cannabinoid (other than smoking)
Opioid, DEA schedule I (e.g., heroin)
Opioid, DEA schedule II-IV (e.g., methadone, oxycodone)
Opioid, NOS
Cocaine
Methamphetamine
Other (specify): _____________
Unknown substance

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'$<6$)7(5+263,7$/$'0,66,21"

□

Hemiplegia
Paraplegia
Quadriplegia

□ Unknown
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□
□
□
□
□
□
□
□

□
□
□
□

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OTHER SUBSTANCES: (Check all that apply)□ None

SMOKING:

6.,1&21',7,21

Cerebral palsy
Chronic cognitive deficit
Dementia
Epilepsy/seizure/seizure disorder
Multiple sclerosis
Neuropathy
Parkinson’s disease
Other (specify): ________________

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Diverticular disease
Inflammatory bowel disease
Peptic ulcer disease
Short gut syndrome

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DSSO\ □ None

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□ HIV infection

Cystic fibrosis

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BBBBBBBBB

□ Unknown

□ Yes □ No □ Unknown

COUNTRY: ____________, ____________, ____________

PATIENT HOSPITALIZED WHILE VISITING
COUNTRY(IES) ABOVE:

□ Yes □ No □ Unknown
PAGE 2 OF 4

Form Approved
Form
Approved
OMB No.
0920-0978
OMBXX-XX-XXXX
No. 0920-0978
Exp. Date:

85,1(&8/785(621/<
. 6,*16$1'6<037206$662&,$7(':,7+85,1(&8/785(

85,1(&8/785(6
21/<25(&25'7+(
&2/21<&2817
________________

Please indicate if any of the following symptoms were reported during the 5 day time period including the
2 calendar days before through the 2 calendar days after the DISC.
Symptoms for patients
≤ 1 year of age only:
□ 8QNQRZQ
□ 1RQH

□ Costovertebral angle pain or tenderness
□ Dysuria
□ Fever [temperature ≥ 100.4 °F (38 °C)]

□ Frequency
□ Suprapubic tenderness
□ Urgency

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□ Apnea
□ Bradycardia
□ Lethargy
□ Vomiting

□ Yes □

No

□ Unknown

4E,)<(6&+(&.$//$17,0,&52%,$/686(',17+('$<6%()25(7+(',6&&KHFNDOOWKDWDSSO\□ Unknown

□ Amikacin
□ Amoxicillin
□ Amoxicillin/clavulanic acid
□ Ampicillin
□ Ampicillin/sulbactam
□ Azithromycin
□ Aztreonam
□ Cefazolin
□ Cefdinir
□ Cefepime
□ Cefiderocol
□ Cefixime
□ Cefotaxime
□ Cefoxitin
□ Cefpodoxime
□ Ceftaroline

□ Ceftazidime
□ Ceftazidime/avibactam
□ Ceftizoxime
□ Ceftolozane/tazobactam
□ Ceftriaxone
□ Cefuroxime
□ Cephalexin
□ Ciprofloxacin
□ Clarithromycin
□ Clindamycin
□ Dalbavancin
□ Daptomycin
□ Delafloxacin
□ Doripenem
□ Doxycycline
□ Ertapenem

□ Eravacycline
□ Fidaxomicin
□ Fosfomycin
□ Gentamicin
□ Imipenem/cilastatin
□ Levofloxacin
□ Linezolid
□ Meropenem
□ Meropenem/vaborbactam
□ Metronidazole
□ Moxifloxacin
□ Nitrofurantoin
□ Omadacycline
□ Oritavancin
□ Penicillin
□ Piperacillin/tazobactam

□ Polymyxin B
□ Polymyxin E (colistin)
□ Rifaximin
□ Tedizolid
□ Telavancin
□ Tigecycline
□ Tobramycin
□ Trimethoprim
□ Trimethoprim/sulfamethoxazole
□ Vancomycin
□ IV
□ PO
□ Other (specify): _____________________
□ Other (specify): _____________________

REMINDER: Any prior antimicrobial use that is not noted above should be documented in the other (specify) field.
5a DID7+(3$7,(17HAVE A
POSITIVE TEST(S) FOR6$56&R9
02/(&8/$5$66$<6(52/2*<25
27+(5&21),50$725<7(672125
%()25(7+(',6&"

Yes
No
Unknown

5F&29,'1(7&$6(,'

5b. IF YES, COMPLETE TABLE BELOW:

Specimen collection date
FIRST positive test for
SARS-CoV-2 on or before the
DISC:
MOST RECENT positive
test for SARS-CoV-2 on
or before the DISC:

5G11'66,'V3/($6(
3529,'($7/($6721(2)7+(
)2//2:,1*:+(1$33/,&$%/(

Test type

/
Unknown

/

□
□
□
□
□

/
Unknown

/

□
□
□
□
□

Molecular assay
Antigen
Serology
Unknown
Other (specify): ____________
Molecular assay
Antigen
Serology
Unknown
Other (specify): ____________

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/RFDOrHFRUG,'
6WDWHFDVHLGHQWLILHU
/HJDF\FDVHLGHQWLILHU
CDC 2019-nCOV ID:

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63(&,0(132/<0,&52%,$/"

□ Yes □ No □ Unknown
26b. WAS THE INCIDENT
SPECIMEN TESTED FOR ESBL
PRODUCTION OR OTHER
BETA-LACTAMASE GENES?

□ Yes
□ No
□ Laboratory not testing
□ Unknown
Version Date: 10/2020

6cIF TESTED, WHAT TESTING METHOD WAS
USED" (Check all that apply):

□ Broth Microdilution (ATI detection)
□ ESBL well
□ Expert rule (ATI flag)
□ Unknown
□ Broth Microdilution (Manual)
□ Disk Diffusion
□ E-test
□ Molecular test (specify):______________
□ Gene variant (specify):______________
□ Other non-molecular test (specify):______________

6dIF TESTED, WHAT WAS THE RESULT:

□ Positive
□ Positive
□ Positive
□ Positive
□ Positive
□ Positive
□ Positive
□ Positive

□ Negative
□ Negative
□ Negative
□ Negative
□ Negative
□ Negative
□ Negative
□ Negative

□ Indeterminate
□ Indeterminate
□ Indeterminate
□ Indeterminate
□ Indeterminate
□ Indeterminate
□ Indeterminate
□ Indeterminate

□ Unknown
□ Unknown
□ Unknown
□ Unknown
□ Unknown
□ Unknown
□ Unknown
□ Unknown

PAGE 3 OF 4

Form Approved
OMB No.
0920-0978
Form
Approved
OMB No. 0920-0978
Exp. Date: XX-XX-XXXX

2686&(37,%,/,7<5(68/76

Please complete the table below based on the information found in the indicated data source. Shaded antibiotics are required to have the MIC entered into the MuGSI-CM system, if available

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Medical Record
ecord
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MIC

Interp

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E-test

Zone Diam Interp MIC

Interp

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□ Yes
Trimethoprim-sulfamethoxazole
□ No

28a. WAS
CASE FIRST IDENTIFIED THROUGH AUDIT?
27G
&200(176

Yes
No
28e. COMMENTS:

CS295460-B

27F62,1,7,$/6

27E&5)67$786

□ Complete
□ Pending
□ Chart unavailable after 3 requests

28b. CRF STATUS:

Complete
Pending
Chart unavailable after 3 requests

28c. SO INITIALS:

28d. DATE OF ABSTRACTION:
___ ___ - ___ ___ - ___ ___ ___ ___

PAGE 4 OF 4